Healthcare Provider Details

I. General information

NPI: 1194758573
Provider Name (Legal Business Name): DIALYSIS CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11135 COLUMBIA ST
BLAKELY GA
39823-3475
US

IV. Provider business mailing address

337 5TH AVE
ALBANY GA
31701-2029
US

V. Phone/Fax

Practice location:
  • Phone: 229-723-5054
  • Fax: 229-723-6121
Mailing address:
  • Phone: 229-888-3996
  • Fax: 229-888-6668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberESRD001080
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000407382A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier00386306A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. DONOVAN SCHULTZ
Title or Position: PRESIDENT
Credential:
Phone: 615-327-3061